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Epos Guide 2012
Epos Guide 2012
EPOS
European Position Paper
on Rhinosinusitus and
Nasal Polyps 2012
Reference
Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, et al. European Position Paper
on Rhinosinusitis and Nasal Polyps 2012. Rhinol Suppl. 2012 Mar(23): 1-298.;
www.rhinologyjournal.com; www.ep3os.org.
Participants
Wytske Fokkens
Chair
Department of Othorinolaryngology
Amsterdam Medical Centre
PO Box 22660
1100 DD Amsterdam
The Netherlands
Email: w.j.fokkens@amc.nl
www.ep3os.org
Valerie J. Lund, Co-Chair
London, UK
Joachim Mullol, Co-Chair
Barcelona, Spain
Claus Bachert, Co-Chair
Ghent, Belgium
Isam Alobid
Barcelona, Spain
Fuad Baroody
Chicago, USA
Noam Cohen
Pennsylvania, USA
Anders Cervin
Helsingborg, Sweden
Richard Douglas
Auckland, New Zealand
Philippe Gevaert
Ghent, Belgium
Christos Georgalas
Amsterdam, the Netherlands
Herman Goossens
Edegem, Belgium
Richard Harvey
Sydney , Australia
Claire Hopkins
London, UK
Nick Jones
Nottingham, UK
Guy Joos
Ghent, Belgium
Livije Kalogjera
Zagreb, Croatia
Bob Kern
Chicago, USA
Marek Kowalski
d, Poland
David Price
Aberdeen, UK
Herbert Riechelmann
Innsbruck, Austria
Rodney Schlosser
Charleston, USA
Brent Senior
Chapel Hill, USA
Mike Thomas
Southampton, UK
Elina Toskala
Philadephia, USA
Richard Voegels
So Paulo, Brazil
De Yun Wang
Singapore
Peter John Wormald
Adelaide, Australia
Peter Hellings
Leuven, Belgium
Table of contents
Objectives & aims 4
Clinical Definition of Acute and Chronic Rhinosinusitis with and without Nasal Polyps 5
Treatment evidence and recommendations for adults with acute Rhinosinusitis
10
13
18
19
20
Reference
Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, et al. European Position Paper
on Rhinosinusitis and Nasal Polyps 2012. Rhinol Suppl. 2012 Mar(23): 1-298.;
www.rhinologyjournal.com; www.ep3os.org.
3
Category of evidence
Ia
Ib
IIa
IIb
III
Strength of recommendation
A
B
C
D
inflammation of the nose and the paranasal sinuses characterised by two or more
symptoms, one of which should be either nasal blockage/obstruction/congestion or
nasal discharge (anterior/posterior nasal drip):
-- facial pain/pressure
-- reduction or loss of smell
and either
endoscopic signs of:
-- nasal polyps, and/or
-- mucopurulent discharge primarily from middle meatus and/or
-- oedema/mucosal obstruction primarily in middle meatus
and/or
CT changes:
-- mucosal changes within the ostiomeatal complex and/or sinuses
Rhinosinusitis in children
Rhinosinusitis in children is defined as:
inflammation of the nose and the paranasal sinuses characterised by two or more
symptoms, one of which should be either nasal blockage/obstruction/congestion or
nasal discharge (anterior/posterior nasal drip):
-- facial pain/pressure
-- cough
and either
endoscopic signs of:
-- nasal polyps, and/or
-- mucopurulent discharge primarily from middle meatus and/or
-- oedema/mucosal obstruction primarily in middle meatus
and/or
CT changes:
-- mucosal changes within the ostiomeatal complex and/or sinuses
Duration of the disease
Acute: Chronic
< 12 weeks
12 weeks symptoms
complete resolution of symptoms.
without complete resolution of symptoms.
(may also be subject to exacerbations)
Acute Rhinosinusitus
To evaluate the total severity, the patient is asked to indicate on a VAS the answer to the question:
10 cm
Not troublesome
Acute Rhinosinusitus
Acute Rhinosinusitus
Level
Grade of
recommendation
Relevance
antibiotic
Ia
yes in ABRS
topical steroid
Ia
Ia
yes in ABRS
Ia
yes in ABRS
saline irrigation
Ia
yes
Ia
ipratropium bromide
Ia
in viral ARS
probiotics
Ia
zinc
Ia
no
vitamin C
Ia
no
Echinacea
Ia
no
Ib
aspirin / NSAIDs
Ib
acetaminophen (paracetamol)
Ib
Ib (1 study)
no
steam inhalation
Ia(-)$
A(-)**
no
cromoglycate
Ib(-)*
A(-)
no
decongestant
no data for
single use
no
mucolytics
no data
no
Acute Rhinosinusitus
Acute Rhinosinusitus
Level
Grade of
recommendation
Relevance
antibiotic
Ia
yes in ABRS
topical steroid
Ia
Ia
yes in ABRS
mucolytics (erdosteine)
1b (-)*
A(-)**
no
saline irrigation
IV
yes
oral antihistamine
IV
no
decongestant
IV
no
10
Acute Rhinosinusitus
11
Chronic Rhinosinusitus
Therapy
Level
Grade of
recommendation
Relevance
steroid topical
Ia
yes
Ia
yes
Ib
unclear
II
during exacerbations
Ib
steroid oral
IV
unclear
mucolytics
III
no
III
no
no data on single
use
no
IV
yes
no data
no
herbal medicine
no data
no
immunotherapy
no data
no
probiotics
Ib (-)
A(-)
no
antimycotics topical
Ib (-)
A(-)
no
antimycotics - systemic
no data
A(-)
no
antibiotics topical
Ib (-)
A(-)
no
* Some of these studies also included patients with CRS with nasal polyps
%
Acute exacerbations of CRS should be treated like acute rhinosinusitis
#
Ib (-): Ib study with a negative outcome
$
A(-): grade A recommendation not to use
** Level of evidence for macrolides in all patients with CRSsNP is Ib, and strength of recommendation
C, because the two double blind placebo controlled studies are contradictory; indication exists for
better efficacy in CRSsNP patients with normal IgE so the recommendation is A. No RCTs exist for other
antibiotics
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Acute Rhinosinusitus
Chronic
Rhinosinusitus
13
Chronic Rhinosinusitus
Level
Grade of recommendation
Relevance
steroid topical
Ia
yes
Ia
yes
Ib
yes
II
during exacerbations
IIb
yes
Ib
III
no
steroid oral
IV
unclear
antibiotics topical
Ib (-) #
A(-) $
no
Level
Grade of recommendation
Relevance
topical steroids
Ia
yes
oral steroids
Ia
yes
Ib
anti-Il-5
Ib
yes
Ib
C**
Ib
unclear
furosemide
III
no
no data
anti leukotrienes
Ib(-)
A(-)
no
anti-IgE%
Ib(-)
unclear
unclear
$
* Some of these studies also included patients with CRS with nasal polyps
#
** Level of evidence for macrolides in all patients with CRSsNP is Ib, and strength of recommendation C, because the
two double blind placebo controlled studies are contradictory; indication exist for better efficacy in CRSsNP patients
with normal IgE the recommendation A. No RCTs exist for other antibiotics.
14
Acute Rhinosinusitus
Chronic
Rhinosinusitus
Evidence-based
Diagnosis
Symptoms present longer than 12 weeks
Two or more symptoms one of which should be either nasal
blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip):
facial pain/pressure,
reduction or loss of smell;
Signs
ENT examination, endoscopy;
review primary care physicians diagnosis and treatment;
questionnaire for allergy and if positive, allergy testing if it has not already been done.
Treatment
For treatment evidence and recommendations for CRSsNP.
Treatment should be based on severity of symptoms
Decide on severity of symptomatology using VAS and endoscope.
Acute exacerbations of CRS should be treated like acute rhinosinusitis.
15
Chronic Rhinosinusitus
Treatment
Therapy
Level
Grade of
recommendation
Relevance
topical steroids
Ia
yes
oral steroids
Ia
yes
1b and 1b(-)
C%
III
capsaicin
II
no
II
no
aspirin desensitisation
II
unclear
furosemide
III
no
immunosuppressants
IV
no
topical antibiotics
no data
no
anti-Il5
no data
unclear
phytotherapy
no data
no
decongestant topical
/ oral
no
mucolytics
no data
no
oral antihistamine in
allergic patients
no data
no
antimycotics topical
Ia (-) **
A(-)
antimycotics systemic
Ib (-)#
A(-)
anti leukotrienes
Ib (-)
A(-)
no
anti-IgE
Ib (-)
A(-)
no
no
$
no
Some of these studies also included patients with CRS with nasal polyps
short term antibiotics shows one positive and one negative study. Therefore recommendation C.
# Ib (-): Ib study with a negative outcome
** Ia(-): Ia level of evidence that treatment is not effective.
$
: A(-): grade A recommendation not to use
*
16
Acute Rhinosinusitus
Chronic
Rhinosinusitus
Diagnosis
Symptoms present longer than 12 weeks
Two or more symptoms one of which should be either nasal blockage/obstruction/
congestion or nasal discharge (anterior/posterior nasal drip):
facial pain/pressure,
reduction or loss of smell;
Signs
ENT examination, endoscopy;
review primary care physicians diagnosis and treatment;
questionnaire for allergy and if positive, allergy testing if it has not already been done.
Treatment
For treatment evidence and recommendations for CRSwNP.
Treatment should be based on severity of symptoms
Decide on severity of symptomatology using VAS and endoscope.
17
Chronic Rhinosinusitus
Level
Grade of recommendation
Relevance
Ia
yes
III
no
topical corticosteroid
IV
yes
no data
unclear
Ib(-)#
A(-)*
no
intravenous antibiotics
III(-)##
C(-) **
no
18
Acute Rhinosinusitus
Chronic
Rhinosinusitus
Diagnosis
Symptoms present equal or longer than 12 weeks
two or more symptoms one of which should be either nasal
blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip):
facial pain/pressure;
cough;
Additional diagnostic information
questions on allergy should be added and, if positive, allergy testing should be
performed.
ENT examination, endoscopy if available;
Not recommended: plain x-ray or CT-scan (unless surgery is considered)
Treatment
For treatment evidence and recommendations for Chronic Rhinosinusitis in children.
This management scheme is for young children. Older children (in the age that adenoids are
not considered important) can be treated as adults.
Acute exacerbations of CRS should be treated like acute rhinosinusitis.
Treatment should be based on severity of symptoms.
19